A Dentist Shortage? Maybe, Maybe Not

In this month’s letter, ADEA President and CEO Dr. Rick Valachovic considers recent U.S. dental workforce projections and shares the perspectives of three deans on what these national trends mean for dental education at the local level.

The dental workforce is aging. More dentists are looking to retire now that the recession is drawing to a close. And despite the increase in graduation rates from U.S. dental schools—5,199 in 2012, up from a low of 3,778 in 1994—we are still producing fewer dentists annually than the 6,300 we produced at a high point in 1978. In view of these trends, we’ve been hearing for years about a looming shortage of dentists. But, is a shortage truly on the horizon? Maybe, or maybe not.

To answer this question, we need to look at demand as well as supply and recognize that what is happening locally may differ dramatically from what is happening across the nation as a whole. What’s more, dentists do not practice in a vacuum, and the current climate for dental practice is in a state of flux. The impacts of the Affordable Care Act, which is reshaping the entire health care landscape, are just beginning to be felt. More children and seniors will be accessing dental care in the years ahead, while most adults are seeking less care. Traditional dental practice patterns are also shifting as more young dentists gravitate toward large-group practices and opportunities in the public sector. Given these developments, what do the latest workforce projections mean for our institutions as they decide how many future dentists to educate and how to recruit and retain sufficient faculty to fulfill evolving needs?

To gain perspective on these matters, I called Marko Vujicic, Ph.D., Chief Economist and Vice President of the Health Policy Institute at the American Dental Association (ADA). After hearing many in our profession express concern that retirements would soon outpace the number of new dentists entering the workforce, I was surprised to learn that only 3,600 dentists retired in 2013, well short of the 5,000 plus students who graduated from U.S. predoctoral programs last year.

“We’re not seeing retirements exceed graduations in many years at all,” Marko told me. “The preliminary projections we have so far indicate either a slightly rising or a stable dentist-to-population ratio over the long term.”

Later this year, to project the future workforce supply, the ADA will release a full report that models dentists’ behavior, but much of the data the ADA has already released elucidates why the workforce may be stabilizing. To begin with, dentists are retiring later. The average retirement age was 69.3 in 2011, up from 64.8 in 2001, a trend that began before the recession and is expected to continue. Concurrently, demand for dental services is reaching a plateau. Even with more older Americans living longer and retaining their teeth, working-age adults are using less dental care, so the ADA projects only a trickle of increased demand for adult dental services in the coming decades if current trends continue.

In short, it may be time to prepare for what the ADA is calling a “new normal.” The association’s projection of per capita dental expenditures from 2010 through 2040 raises two concerns of immediate interest to our community:

Total per capita dental expenditures are expected to grow in the next 30 years but at a much lower rate than during the past few decades.

The sluggish growth combined with an expansion of dental school enrollment could potentially lead to challenging economic conditions for practicing dentists, who already saw their incomes decline between 1992 and 2009.

A separate ADA brief reported that more than a third of dentists surveyed, including 42% of solo practitioners, said they were “not busy enough” in 2012. From an economic perspective, as Marko pointed out, these figures indicate that the system has excess capacity. It just may not be where it is needed or available to the patients who need it.

That idea resonates with Mark Latta, D.M.D., M.S., Dean of Creighton University School of Dentistry. He, too, has seen the numbers indicating that there are enough dentists to meet current demand, but from where he sits, he sees plenty of unmet need. He says the problem is particularly acute in rural areas in Nebraska and on Indian reservations in neighboring states. In other words, there may be plenty of dentists in the aggregate, but they aren’t necessarily located in areas of need.

“The facts are, 30–35% of the population still doesn’t see a dentist, and the demography of active caries is heavily skewed to this population,” Mark observed when we spoke last month. “There’s plenty of care that needs to be delivered, and we’re going to need dentists to deliver that care.”

A similar appraisal is shaping policy in Connecticut. The state, which is putting systems in place to try to fund care for its low-income residents, recently approved a decision to expand enrollments at the University of Connecticut School of Dental Medicine by 12 students per class. Dean Monty MacNeil, D.D.S., M.Dent.Sc., points out that although Connecticut may be the second wealthiest state per capita in the nation, it has four of the country’s 10 poorest cities, producing a significant disparity in oral health services within the small state.

“The state has enough dentists to treat its population, but they are maldistributed, and for us, the greatest problem is urban versus rural,” Monty told me, echoing Mark’s comments. “We believe that as a state-supported institution, we have a mission to treat those who cannot seek care elsewhere. To a certain extent, we can be the equalizer.”

But educating those additional students won’t be easy—at this school or anywhere else. The aging of the dental workforce also means that academic dentistry will soon be losing a significant portion of its faculty to retirement. Monty expressed particular concern about attracting and retaining research faculty. Across the board, faculty recruitment is a concern because competition for academic talent is rising with so many schools opening or expanding in recent years.

Mark Latta is already confronting this issue at Creighton, where 50% of the full-time faculty is over age 60 and 35% is over age 65.

“I’m going to see a massive transfer of intellectual capital,” he told me.

To manage the transition, the dental school at Creighton has put several forward-looking programs in place. First, the school has created half-time, benefit-eligible positions for retiring faculty to phase their departures. The school has also created a mentorship process to bring new faculty up to speed more quickly. To retain current faculty, Creighton has begun offering stipends and loan forgiveness to individuals who want to pursue graduate training and agree to return to teach. These approaches appear to be working, but private sector salaries still constitute a major challenge to the school’s efforts to recruit graduates to pursue academic careers. Mark estimates that Creighton will need to increase faculty salaries by 30% if the school is to continue to succeed in recruiting dentists, especially specialists, to full-time positions.

At the University of Texas Health Science Center at San Antonio Dental School, Dean Bill Dodge, D.D.S., is more relaxed about the coming faculty shortage than anyone else I’ve talked with of late, perhaps illustrating once again that numbers in the aggregate may be misleading. Conditions on the ground in San Antonio give Bill cause for optimism. To start with, the school runs a teaching honors program that has graduated more than 100 students to date, of whom 11 are currently affiliated with an academic institution, either a dental school or specialty program. The school has also received a four-year Health Resources and Services Administration grant to recruit and prepare Hispanics for successful careers in academic dentistry.

Bill is especially encouraged by alumni who have recently expressed interest in returning to their alma mater to teach. To make teaching financially attractive, Bill is exploring ways to alter the school’s faculty practice plan by increasing the time available for practice and by ensuring there are adequate incentives for productivity. If structured properly, he believes such a plan would generate revenue for the dental school and allow part-time faculty to earn salaries within striking distance of those earned in private practice.

“We have two people now who want to join the faculty who may prove to be models for the future: a midcareer individual who wants to move an active clinical practice to the school and a young person who wants the opportunity to teach while simultaneously growing her intramural practice,” he told me. “They are exactly the kind of people we need, and not just for financial reasons. They’re the best role models we have to demonstrate the faculty career as a viable option.”

Bill even sees a silver lining in the utilization of dental services data gathered by the ADA. “Visits are down, per capita expenditures are down, incomes have begun to dip. In a way, that could work to our advantage by shrinking the gap between private practice and academic salaries,” he conjectures.

Not everyone would go that far, but his point does lend support to the idea that the reality we have taken for granted these past few decades is giving way to a new reality that may have unforeseen benefits as well as costs. So do we have a shortage of dentists?

As Monty observed, we clearly needed the rebound in educational capacity following the dental school closures of the 1980s, but in light of recent developments, he suggested that we may be at the stage where we should stabilize our graduation rate. At least it might behoove us to analyze where we are.

To quote Marko Vujicic: “It’s an interesting puzzle. We have over all pretty sluggish growth in demand, except among the Medicaid population, seniors and children. So the key question for the dental education community is, are you training the ‘right’ kind of dentists? Are you training your graduates so that they can work in settings where the demand for dental care will grow?”

These are good questions, ones our community would do well to consider.

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This is an excellent article. It uses current, relevant information to envision what the future of dentistry may look like, and it has important implications for curricular changes in our educational programs.

A Dentist Shortage? Maybe, Maybe Not. Very balanced article. A few points:

1. ARTICLE QUOTE: “And despite the increase in graduation rates from U.S. dental schools—5,199 in 2012, up from a low of 3,778 in 1994—we are still producing fewer dentists annually than the 6,300 we produced at a high point in 1978.”

Remember, the 6,300 dentists that graduated in 1978 was an artificially high number of dentists (supply) for the dental demand for services (demand) and that imbalance created a problem for the profession and dental schools that took decades to work through. One of the major causes for the excessive number of graduating dentists in 1978 was government offering money to dental schools (in the late 1960’s) in exchange for increasing their graduating class sizes. Grants were doled out to schools willing to change from the traditional 4 year curriculum to a 3 year curriculum. The net gain from this change was an immediate and dramatic increase in class sizes, flooding the dental marketplace with more dentists than the true demand for services. It took ten years after this high point in 1978 to reach crises proportions in the late 1980’s and early 1990’s when dental applications bottomed out and several major dental schools closed.

2. The artificially high number of graduating dentists in 1978 led to what we saw in the 1980’s, a rapid growth of “mall dental practices” popping up everywhere by entrepreneurial corporate-thinking dentists. They offered low wage clinical positions to our graduates, taking advantage of the oversupply of dentists. Young graduates felt pressured to ‘find disease to treat’. The same thing is happening today. The names and faces have changed, but the free market reaction to too many dentist is the same. Now, corporate dental practices are popping up everywhere. The supply/demand ratio once again favors the corporate model…a gold mind for shareholders, but a bane for the average dentist working for them.

3. ARTICLE QUOTE: “Traditional dental practice patterns are also shifting as more young dentists gravitate toward large-group practices and opportunities in the public sector”. The implication is the modern dental graduate ‘prefers’ other options compared with traditional opportunities. Yes, with today’s student debt and competition for patients, new graduates may gravitate toward large corporate practices and the public sector. But don’t be fooled; most dentists want to be their own bosses and do not prefer to be an employees for someone else.

What’s interesting is how history repeats itself. In the 1960’s, to create a glut of dentists, government offered money for schools willing to go from a 4 year curriculum to a 3 year curriculum. More recently, government has artificially stimulated the number of graduating dentists by offering cheap money to dental school applicants keeping the line of applicants outside dental school doors very long for quite some time. 25 years ago it was ‘mall practices’ popping up everywhere. Today it is ‘corporate practices’ with shareholders. The climate for the average practicing dentist just isn’t that good.

What’s the lesson?

Schools (like most institutions) operate in a fishbowl, dealing day to day with issues (like growth and survival) nearly oblivious to what is going on outside their walls. The best way to protect and take care of dental schools is to protect and take care of the profession. Be mindful of the well-being of your average working ‘Joe’ clinician. If we don’t, ultimately it will be to the detriment (possible demise) of dental schools themselves. If we graduate hordes of tooth carpenters looking for work that just isn’t there, we diminish the profession and turn our representatives into tradesmen, with our schools becoming trade schools. And ultimately, the public is not better served either. Corporations and big business will never replace caring professionals taking care of people.